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FOR OFFICE USE- APPLICATION FOR SANITATION PERMIT �IComplete in_Triplicatel. Permit No. .7��_ ...... •............:................................. y ' . _. . . .. . ... . ....�.©ate Issued "7z This permit Expires t Year from Date Issued Application is hereby made to the Sah'Joaquin Local Health District for a permit to construct and install the work herein described. This application is made inwcompliance with County Ordinance No. 549 and existing Rules and Regulations: .JOB ADDRESS/LOCATIO ��$ � ..- ..- ..--.--- E ...................--- --��--------c ---...._..........:.._.. ......................_.....CENSUS TRACT ------- ----- Owner's Name •- - ---------------- .......... •---- ............Phone .... • .._ ....----- ...------- ��`f 6g Address ...City �. _.. _... ...................................... ._..... .... - s Contractor's Name_ License - ........... Phone Installation will serve: Residence❑Apartment use Commercial OTrailer Court Q Motel ❑Other ..........:........ . Yf � Number of-living.-units.............).. Number of,bedrooms ____........Garbo e i r . ._-._...__ Lot Size ......_...5.. ............................. Water Su l P blic S tem and name .... i ........ ..... ...................:_ pp Y= Y !!! ..............................Private❑ Character of soil to a depth of 3 feet. Sand 0 Silt[3 Clay .Q Peat❑ Sandy Loom 0 Clay Loam tj 1 ._. . .. ,.9 1f Hardpan❑. _Adobe X Fill Material ............ If yes,type Q ..... (Plot plan, showing size of lot, location of system In relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION;— (No septicrtank or seepage pit perrhitted"-if pui;lii:sewer is civailabie within 204 feet,} PACKAGE TREATMENT f I SEPTIC TANK I I Size................................................ Liquid Depth •-----_-...___............ Capacity ............. Pa tY Type --------=-=- -------- Material_.........,............ No. Compartments .................. Distance-to nearest: Well ' ..........._Foundat€an ................... Prop. Line _ g NG LINE f j- No: of Lines -___-___________ ______ Length of each line--------------- Total Length LEACH! - -----------•--•------------�� i `D' Box .s.'.-•_--- Type Filter Material ....................Depth Filter Material ...................I........................ Distance to nearest: Well ........................ Foundation .................. Property Line .......................... SEEPAGE PIT [ Depth -_--i.............. Diameter __.............. Number ............................ Rock Filled' Yes ❑ No Q .�� WQtetTable Depth".. .. � .....Rock Sits - 4 Distance to nearest: Well ........................................Foundation`.:: :`.::...::.:.... Prop. Line ---._.__._..----•- -- , REPAIR/ADDITION(Prev. Sanitation) Permit . ... Date ............................. - ---- Septic Tank (Specify Requirements) __- - ......... .............................. ......... .:...w.:..... Disposal Field Ify Requirements) 4_1j_ i 11 -'•• -, -�•- -- __ T-�____ _ _ .. ..............•_•-------------•---•-------•__-_`'.__9__:-._.:.s...................................._......................................... (Draw existing and required addition on reverse side) 1 hereby certify that I have prepared this application and that the work ivill be done in accordance with San Joaquin County Ordinances, State Laws, acid Rules and Regulations of the San Joaquin Local Health.01slrict. Home owner or licen- sed agents signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, i shall not employ any person in such manner as to be a sub(e to Workman•1 Compe cation I x f California." Signed Owner BY ----- ---------------------------------- ..: . •_.--- --------- Ji tle _....,...... -----•-•---- ------------- --------._ .............. ° ---.. ------------------------ (if other than owner) t FOR DEPARTMENT .USE ONLY APPLICATION ACCEPTED BY _..__ .. --------------------:---•------------.•-•------•--•----- .......---------_.......... DATE..--- .1�1�-` ------.- ..___. . . BUILDING PERMIT 15SUED ----------•--• ... ©ATE -... ADDITIONAL COMMENTS -------- --------------- --•---- L •----'----.............................................._. ......_.---------...................---------------------------------------------^-- -------•-------•------•--•- -------------- ........-_............................ .-..............•:.... --•-- Final Inspection by !..-_..... R . _..........Date ...... /+ -- ............ .. .......---•- EH 13 2h 1-68 Rev. SAN JOAQUIN LOCAL HEARTH DISTRICT 8/7h 3M